Psychosis and the city

In the covid crisis some persons did better! More and more people stated that they enjoyed the quiteness. Is noise and just bustle an explanation for the finding that there is more psychosis in the big cities? In this item you can find new research.

Psychosis and the city : what is the problem ? and is the problem not also the solution?

With links to papers from the journal Psychosis (free for isps members) or link to papers with open access.

See also fragmented neighbourhoods under epidemiological findings

Since the 1930s (Faris and Dunham, 1939), we are aware of a direct relation between psychosis and living in densely populated areas (cities). During the last two decades, well- controlled epidemiological studies have shown that urban birth, urban upbringing (first 10 years) and current city living are correlated with a higher risk of psychotic episodes (more than twofold) (See Vassos 1). These correlations are also present for other disorders but to a lesser extent, and have been controlled for several biases like cannabis consumption.
We however don't know yet in detail what underlies this correlation and what it really means. So, if there is a strong and specific link between psychosis and the city : what is the problem ? (See Abrahamyan 2)

Epidemiologic studies point out stress factors in the urban environment: social stressors and socio-environmental adversity, increased by low social cohesion and high deprivation (e.g. low income, employment and education), inequality and social fragmentation. Looking at brain structure, people who grew up in cities show a difference located in the same area that the one linked to exposure to psychosocial stress (see Haddad 3.) In sum, social adversity (related to population density, social fragmentation and deprivation) appears as the factor most responsible for the correlation between urban living and psychosis (See Heinz 4.)
In addition, lack of green space (in itself or as proxy for urban stress), environmental pollution and toxin exposure have been suggested to increase risk (See Fett 5).

From this point of view, people living with psychosis emerge as the sensitive social witnesses of negative aspects of urban living and In this context, research on the psychosis-city nexus helps us to understand what happens to everyone, but with variegated levels of intensity, when living in dense urban areas. Therefore, we can see psychosis acting as an alarm organ for the society as a whole. In a recent research in Switzerland, a research team worked with FEP (first episode patients) and videotaped going alongs in the city to find out, from patients' point of view, how they experienced urban stress and urban well-being (Söderström 6-7 ).
The research showed that density, high levels of sensory stimulations and unchosen social interaction where main elements of urban stress, while the creation of sensory 'bubbles' (through conversation or using headphones), carefully programming urban pathways and searching for calm niches were the tactics patients used to handle urban stress.
Another of the key findings was that FEP change the way they live in cities after a first episode and tend to avoid dense areas (Conus 8). However, if urban areas constitute part of the problem in psychosis, they are also, as resourceful environments (for employment, education, social interaction), part of the solution. Features of urban areas can bring you into a downward spiral while others can lead you into an upward spiral. The team now works on 'urban remediation': a strategy involving patients, peer practitioners, psychiatric services, but also ordinary citizens and municipalities to design this upward spiral and promote an emplaced recovery from psychosis (Baumann 9).

1. Vassos E, Pedersen CB, Murray RM, Collier DA, Lewis CM. Meta-analysis of the association of urbani
city with schizophrenia. Schizophr Bull. 2012 Nov;38(6):1118-23. doi: 10.1093/schbul/sbs096. Epub 2012 Sep 26. PMID: 23015685; PMCID: PMC3494055.

2. Lilith Abrahamyan Empson, P Baumann, Z Codeluppi, Ola Söderström, Dag Söderström, Philippe Conus. Urbanicity: The need for new avenues to explore the link between urban living and psychosis. Early intervention in psychiatry 2020, vol 14,issue 4, pp 398-409

3. Haddad L, Schäfer A, Streit F, Lederbogen F, Grimm O, Wüst S, Deuschle M, Kirsch P, Tost H, Meyer-Lindenberg A. Brain structure correlates of urban upbringing, an environmental risk factor for schizophrenia. Schizophr Bull. 2015 Jan;41(1):115-22. doi: 10.1093/schbul/sbu072. Epub 2014 Jun 3. PMID: 24894884; PMCID: PMC4266290.

4. Heinz A, Deserno L, Reininghaus U. Urbanicity, social adversity and psychosis. World Psychiatry. 2013 Oct;12(3):187-97. doi: 10.1002/wps.20056. PMID: 24096775; PMCID: PMC3799240.

5. Anne-Kathrin J. Fett,a,b,c Imke L.J. Lemmers-Jansen,b and Lydia Krabbendamb,c. . Psychosis and urbanicity: a review of the recent literature from epidemiology to neurourbanism. Current Opinion in Psychiatry. Curr Opin Psychiatry. 2019 May; 32(3): 232– 241.
6. Söderström O, Empson LA, Codeluppi Z, et al. Unpacking "the City": An Experience-Based Approach to the Role of Urban Living in Psychosis , Health & Place, 2016 ; 42 : 104-110.

7. Söderström O, Söderström D, Codeluppi Z, et al. Emplacing Recovery: How Persons Diagnosed with Psychosis Handle Stress in Cities , Psychosis, 2017 ; 1-8.

8 Conus P, Abrahamyan Empson L, Zoe Codeluppi, P Baumann, Ola Söderström, Dag Söderström, P Golay. City Avoidance in the Early Phase of Psychosis: A Neglected Domain of Assessment and a Potential Target for Recovery Strategies,. Front. Psychiatry, 03 June 2019.

9. Baumann, P.S., Söderström, O., Empson, L.A., Söderström, D., Codeluppi, Z., Golay, P., Birchwood, M., Conus, P., 2020. Urban remediation: a new recovery-oriented strategy to manage urban stress after first-episode psychosis. Social psychiatry and psychiatric epidemiology 55 (273-283), 1-11.


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